The collaboration in Medical Ethics started in 1992 between the University of Colombo (professor Nalaka Mendis) and the University of Oslo (professor Reidar K. Lie) with funds from NORAD. Professor Lie is now at the University of Bergen. A number of activities have been initiated within this collaboration (see Report of activities). These activities prove that this is a viable collaboration, and that it is now justified to expand it to a new phase.
Programme idea, background and relevance
Although Sri Lanka has a per capita gross domestic product of about USD 600, it has an impressive record with regard to health care delivery, with a high life expectancy (72 years) and a low infant mortality rate (22/1000). There are, however, a number of problems in the Sri Lankan health care delivery system that need to be addressed. These include an illdefined relationship between the central and the peripheral areas and between the private and the public sectors. There are deficient decision-making procedures and a lack of monitoring procedures. These deficiencies result in the mismanagement of funds, affecting not only the internal distribution of resources, but also foreign donations. For example, foreign donors eager to upgrade the rural health care delivery system have provided expensive equipment to rural hospitals based on the recommendation of Sri Lankan officials. However, as there is no expertise in the rural areas for maintaining or running this equipment, it remains unused. Similarly, one can point to a number of large hospital or health care projects, some of which are in the planning process, which, through a combination of foreign donor ignorance of key features of the Sri Lankan health care delivery system and a lack of public and accountable decision making procedures in Sri Lanka, have resulted in waste of foreign donations.
Professor Nalaka Mendis has established a core group of people in Colombo who are working in the field of Medical Ethics. This core group has been responsible for organising a variety of workshops on issues in health care aimed at different groups. As a result of this activity, an open forum has been created where professionals from a wide variety of backgrounds and institutions can discuss issues in health policy openly. This is the only forum of this kind in Sri Lanka, and the only forum for open and frank discussion between the different groups involved in setting health policy in an atmosphere of mutual trust. This was particularly evident in the June 1995 meeting. Partly as a result of this meeting an Advisory Committee on Health Policy has been established by the Minister of Health. In 1993 a Report on the formulation of a national health policy was published by (Presidential Task Force, 1993). The plan is now to continue to take advantage of the forward momentum that has been created by establishing a long-term collaboration in health policy between the University of Bergen and the University of Colombo.
If the current effort by the Sri Lankan Ministry of Health to improve the Sri Lankan health care system is to succeed it is necessary that there is a group of people in Sri Lanka who have competence in ethics and health policy. Many of the key decisions will involve difficult ethical issues. The aim of this project is therefore to train a group of researchers with this needed expertise. This group would be responsible for carrying out needed research in ethics and health policy, for building competence in questions of ethics and health policy and to prepare policy recommendations. The group would be independent, yet, through the forum of open discussion already established with the key persons involved in setting health policy, would be able to work in close collaboration with the decision-makers, thus being able to influence directly health policy in Sri Lanka.
There is a growing recognition internationally of the need for policy analysis if the proposed health care reforms, such as the Alma Ata Conference and its goal of "Health for All by 2000", are to succeed (see for example, Walt and Gilson 1994). A narrow emphasis on economics and technical issues is not sufficient. Ethical analysis is a key component of such a policy analysis (Carr-Hill 1994; Dujardin 1994). There is, however, right now a lack of expertise in this field.
There is no question that there is a need for such a health policy group in Sri Lanka. Norway, through NORAD and the Center for Medical Ethics in Oslo, has already been directly involved in laying the foundation for the establishment of such a group, and Norway will now have the unique opportunity to continue to be involved in this project. The results of this collaboration will be directly relevant for questions of health policy in Norway, as many of the issues are structurally similar. The results would also provide a model for the efforts of other countries to examine the ethical basis for questions of health policy, and we expect the results to be applicable to other countries as well.
The main aim of the project is to establish a Research Group in Medical Ethics in Colombo which will be a resource group and a focal point for the examination of ethical issues in health care in Sri Lanka. The main focus of the activities of this core group will be ethical issues in health policy. Medical Ethics will give the health policy analysis the needed interdisciplinary emphasis, and ensure that the central focus will be on questions of value, rather than on technical issues, such as economic efficiency. Through the establishment of this Research Group, a group of researchers will be trained in the field of ethics and health policy.
A structured programme of workshops on a variety of issues related to ethics and health policy will be developed. This programme of workshops will be the main tool to create expertise in ethics and health policy in Sri Lanka. The topics will, however, also be related to current problems within the Sri Lankan health care system. The activities will therefore also produce specific policy recommendations.
The group will initiate its investigation to ethical issues arising out of the provision of health care services through both a public and a private system. This is currently an important issue in Sri Lanka as well as in Norway. Norway has a comparatively small private health care sector, but there are increasing demands that services which are not available in the public sector, or only available after long waiting periods, should be provided in the private sector. Sri Lanka has a comparatively large private sector of health care. Some of the important issues are what obligation a Government has to provide health care for its citizens, and what the basic package of health care should contain.
This issue is particularly important because of efforts by such agencies as the World Bank to attempt to increase efficiency by introducing elements of competition and user charges in the health care sector (see Broomberg 1994; World Bank 1993). One issue that will be examined is whether these proposals are compatible with the ethical demand of an equitable health care system.
The participants in the workshops will prepare working papers that will be circulated prior to the meeting and discussed during the workshops. The working papers will be revised to position papers and policy recommendations. The topics of the working papers and the distribution of tasks among the group members will be decided during the first workshop in January 1996. Some of the proposed topics will be: Statistics on the use of private funds for health care; descriptive analysis of the problems of private-public interaction in health care; examination of policy documents (such as the one issued by the Dutch government, Government Committee on Choices in Health Care, 1992) on two-tiered systems; a normative analysis of private-public provision of health care.
In addition to this structured programme of workshops on topics directly relevant to ethics and health policy, the researchers from Sri Lanka will take part in intensive courses offered on ethical theory, general medical ethics, and issues in international health in Bergen and in Colombo. These courses will provide the necessary general education necessary to create experts in this area. Both M.A. candidates and post.doc. trainees will participate in these seminars. The courses will be part of a planned Master's program in International Medical Ethics offered at the University of Bergen.
During the program period long term collaborative research projects on areas of common interest in this field of research will be developed.
The proposal also consists of the necessary infrastructural investments in a library (books and journals), and limited equipment.
Expected output, specific objectives
1. Completion of two M.Phil. degrees in medical ethics
2. Training of two senior lectures in Ethics and health policy
3. A series of working papers and position papers on ethics and health policy
4. Initiation of research collaboration between Norwegian and Sri Lankan researchers on issues of ethics and health policy
Programme period and termination of programme
The project in its present form will terminate by the end of this programme period (1999). By that time the needed infrastructure and the necessary expertise in Ethics and health policy will have been established in Colombo. The programme will at that time continue in the form of a research collaboration between Norway and Sri Lanka with funding on specific research projects.
Broomberg J. Managing the health care market in developing countries: prospects and problems. Health Policy and Planning 1994;9:237-251
Carr-Hill RA. Efficiency and equity implications of the health care reforms. Social Science and Medicine 1994;39:1189-1201
Dujardin B. Health and Human Rights: The challenge for developing countries. Social Science and Medicine 1994; 39:1261-1274
Government Committee on Choices in Health Care. Choices in Health Care. Ministry of Welfare, Health and Cultural Affairs, The Netherlands, 1992
Presidential Task Force. Report of the Presidential Task Force on Formulation of a National Health Policy for Shri Lanka. Department of Government Printing, 1993
Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy and Planning 1994;9:353-370
World Bank. Investing in health. World Development Report 1993. The World Bank, Washington DC, 1993